MARMARA

MEDICAL JOURNAL Original Article

https://dergipark.org.tr/tr/pub/marumj

An effective and practical tool to assess physical frailty in older adults:

Turkish validation of the FRAIL Scale
Ben Azir Begum HYMABACCUS1 , Rana TUNA DOGRUL1 , Cafer BALCI1 , Cemile OZSUREKCI1 , Hatice CALISKAN1 ,
Erdem KARABULUT2 , Meltem HALIL1 , Mustafa CANKURTARAN1 , Burcu Balam DOGU1

1
Division of Geriatric Medicine, Department of Internal Medicine, School of Medicine, Marmara University, Ankara, Turkey
2
Department of Biostatistics, School of Medicine, Hacettepe University, Ankara, Turkey
Corresponding Author: Rana TUNA DOGRUL
E-mail: rana_tuna@hotmail.com

Submitted: 18.10.2022 Accepted: 23.03.2023

ABSTRACT
Objective: Practical scales with tested validity and reliability are needed to clinically determine frailty.The aim of this study is to find
out whether the Fatigue, Resistance, Ambulation, Illnesses, and Loss of weight (FRAIL) Scale is an effective screening scale to show
frailty.
Patients and Methods: The Frail non-Disabled (FIND) scale validated in the Turkish population was applied for FRAIL Scale validation.
Comprehensive geriatric assessment and Fried Index were performed on 85 outpatients who were 65 years and older. The patients were
examined in terms of comorbidity, number of falls, living environment, number of drugs used, and hospitalization in the last year.
Results: The FRAIL Scale had a high correlation with the FIND scale and Fried Index (correlation coefficients are 0.956 and 0.934,
respectively). In addition, it was found to be associated with Activities of Daily Living (ADL), Instrumental Activities of Daily Living
(IADL) scales, the Mini-Mental State Examination (MMSE), Yesavage Geriatric Depression Scale (GDS), Mini Nutritional Assessment
short-form (MNA-sf),Clock Drawing Test (CDT), handgrip strength, and timed up and go test (p<0.05). The compliance between
independent practitioners and test-retest compliance were found to be 100% (full compliance,Cronbach’s alpha coefficient is 1.00).
Conclusion: In the Turkish geriatric population, the FRAIL scale was found to be a reliable and valid scale in showing frailty.
Keywords: The FRAIL Scale, Frailty, Comprehensive geriatric assessment

1. INTRODUCTION
Frailty is defined as the state of weakness arising from the
decrease in physiological reserves caused by physiological
changes, diseases, and/or inadequate nutrition, etc. with
advancing age [1]. Frailty is characterized by the impairment in
adaptation to stress conditions such as acute disease and trauma
depending on the decrease in the reserve in neuromuscular,
metabolic, and immune systems [2]. This topic is gaining
more and more important since frail older patients go through
mortality, morbidity, and health expenditures when they are
exposed to stress factors [3, 4].
As frailty is a dynamic process, it is of great importance
to determine the frail population and provide appropriate
treatment. According to a consensus involving international
communities, all patients 70 years of age and above, those with
chronic diseases, and individuals who have lost more than 5%
weight over the last year should be screened for frailty [5].
There are many risk factors for frailty in older people [6]. Since
frailty is a multifactorial clinical condition, it is quite difficult to
measure [7]. Many easily applicable and reliable methods have
been developed to determine frailty in geriatric clinics. “The
Fatigue, Resistance, Ambulation, Illnesses, and Loss of weight
(FRAIL) Scale developed by Morley et al., consists of five items
[8]. In many countries, the FRAIL Scale has been validated and
proved to be an effective method in determining frailty [9-13]. It
allows for evaluation via the investigation of the patient’s state of
fatigue, resistance, weight loss, and other diseases. When it was
first created, the FRAIL Scale was rather for measuring frailty
in middle-aged Americans of African origin. However, it has
been proved to be a reliable frailty scale in older patients living
in many different societies. In the validity and reliability study of
the FRAIL Scale on a Mexican population aged 60 and above in
2016, it was found to be a reliable scale in Mexican society, and

How to cite this article: Hymabaccus BAB, Dogrul TR, Balci C, et al. An effective and practical tool to assess physical frailty in older adults:
Turkish validation of the FRAIL Scale. Marmara Med J 2023: 36(2):149-156. doi: 10.5472/marumj.1297696

© 2023 Marmara University Press, All Rights Reserved http://doi.org/10.5472/marumj.1297696

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ISSN: 1309-9469 Marmara Med J 2023;36(2): 149-156

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Turkish validation of the FRAIL Scale
associated with mortality, duration of hospital stay, dependency,
and falls [10]. In the validation study of the FRAIL scale in
Australia in 2015, it was proved to be a reliable frailty scale [12].
In the study conducted on 1,235 older people in China in 2017,
the validity and reliability of the FRAIL Scale was proved [11].
There are no gold standard tests to measure frailty today, and the
number of frailty measurement tests is quite high as well. In this
study, it was aimed to reveal whether the FRAIL scale was an
effective screening scale to show frailty. Frail non-Disabled (FIND)
scale was used for FRAIL Scale validation in the Turkish population.
2. PATIENTS and METHODS
Participants
Eighty-five individuals, who presented to the Outpatient Clinic
of Geriatric Medicine between March and July 2017, were 65
years old and older, agreed to participate in the study, and had
the capability of understanding and answering the questions,
were included in the study. Criteria of exclusion from the study
were determined as follows: (1) Presence of active malignancy,
(2) Patients with physical disabilities (extremity amputations,
sequelae due to stroke, problems with speaking and hearing), (3)
Patients with acute infections, (4) Patients with acute diseases
(decompensated congestive heart failure, recent myocardial
infarction/stroke, chronic obstructive pulmonary disease
exacerbation), (5) Patients who were hospitalized or had an
operation in the last month, (6) Patients with dementia at an
advanced stage, (7) Patients unable to tell their medical history
and not cooperating, (8) Patients with organic psycho-affective
disorder and organic degenerative disease.
The patients were examined in terms of education status, gender,
height and weight, smoking, alcohol consumption, living
environment, number of falls in the last year, hospitalization
in the last year, presence and type of urine incontinence, the
status of vaccination, the number of drugs used, and presence
of comorbidity. Furthermore, gait speeds (4.57 meters) and
handgrip strengths (hand-held dynamometer (Takei A5401,
Japan) determined during the examination were recorded.
Individuals were asked about the hand they use in daily life
activities such as eating and writing and in activities requiring
power, and the hand they use for these tasks was determined as
the dominant hand. The handgrip strength was measured with
a Handgrip Dynamometer (Takei A5401, Japan) (measured by
grip strength with a hand dynamometer). Measurements were
made when the patients were standing, with the elbow and
wrist in full extension. Measurements were repeated three times
with intervals of five seconds, recorded in kilograms, and then
averaged. For the gait speed test, the person was asked to walk a
distance of 4.57 meters at a normal speed as in his daily life, and
the duration of walking the 4.57 meters distance was calculated
in seconds. The test was run 2 times and the best score achieved
was recorded. The walking speed was recorded in m / sec by
dividing the distance into the recorded times.
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The FRAIL Scale
The FRAIL Scale is a test consisting of 5 questions, and an
evaluation is made by investigating the patient’s state of fatigue,
resistance, ambulation, weight loss, and illnesses. To evaluate the
state of fatigue of the patient, “How much of the time during the
past 4 weeks did you feel tired?” is asked as the first question.
The patient chooses one of 1=All of the time, 2=Most of the
time, 3=Some of the time, 4=A little of the time, and 5=None of
the time; if the patient’s answer is 1 or 2, 1 point is given whereas
the others get 0. To measure the resistance of the patient, “By
yourself and not using aids, do you have any difficulty walking
up 10 steps without resting?” is asked as the second question; if
the patient says yes, 1 point is given, if no, then 0. To evaluate
the ambulation of the patient, “By yourself and not using aids,
do you have any difficulty walking several hundred meters?”
is asked as the third question; if the patient says yes, 1 point is
given, if no, then 0. To evaluate the illnesses of the patient, “Did
a doctor ever tell you that you have (illness)? “ (Hypertension,
diabetes, cancer (except for small skin cancer), chronic lung
disease, heart attack, congestive heart failure, angina, asthma,
arthritis, stroke, kidney disease). If the patient has 0-4 diseases,
0 point is given; if 5-11 diseases, then 1 point. To evaluate weight
loss, “How much do you weigh with your clothes on but without
shoes? (current weight)” “One year ago, how much did you
weight without your shoes and with your clothes on?” (Weight
one year ago) are asked, and the percentage of weight change is
calculated. If the weight change is above 5%, 1 point is given. In
the FRAIL Scale, which consists of 5 items, 0 point is considered
non-frail, 1-2 points pre-frail, and >2 points frail [8]. Patients
participating in the study were evaluated as blind in terms of
comprehensive geriatric assessment (CGA) and FRAIL Scale.
Reference Tools
Various screening and assessment tests are used for an
objective, comprehensive geriatric assessment. As part of
the comprehensive geriatric assessment, history, physical
examination, geriatric syndrome questioning, and tests related
to geriatric syndromes were performed. These include the Katz
Activities of Daily Living (ADL) scale [14, 15], Instrumental
Activities of Daily Living (IADL) scale [16], the Mini-Mental State
Examination (MMSE)[17, 18], Mini Nutritional Assessment
short-form (MNA-sf) [19, 20], Yesavage Geriatric Depression
Scale (GDS) [21], 4.57-meters walking test and clock-drawing
test (CDT) [22]. The patient’s age, demographic characteristics,
comorbid diseases, social status, cognition, mood, functionality,
nutritional status, and geriatric syndromes were evaluated and
recorded. A researcher who participated in the study recorded
whether the patients were clinically frail or not according to the
comprehensive geriatric assessment. These tests were applied to
the patients by a geriatrician in the geriatrics outpatient clinic.
Verbal responses were obtained from the patients.
The FIND scale was developed by Cesari et al. in 2014 [23, 24].
The FIND scale consists of 5 questions: 2 questions are about
disability (walking 400 meters and climbing up one floor) and
3 questions are about frailty assessment (weight loss, fatigue,
and physical activity). It ranges between 0-5 points, and the state
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of disability and frailty is determined according to the score
received. If the patient gets 1 point from the first 2 questions, it
is considered to be a disability, and if the patient scores zero, the
other 3 questions are asked. If the patient gets 1 point from these
questions, it is considered as frail.
The patients were subjected to the Fried Index. In the Fried Index,
involuntary weight loss, fatigue stated by the individual, weakness,
slow gait speed, and low physical activity are assessed [25]. Weight
loss (1): The patient has an unintentional weight loss of 4.5 kg or
more compared to the previous year, or a weight loss of 5% or
more in body weight at follow-up compared to the previous year.
The state of exhaustion (2) was determined by 2 questions on the
Center for Epidemiological Research – Depression (CES-D) scale:
How often in the last week you felt that everything you did was
an effort?’ and ‘How often in the last week you felt that you could
not go out? Participants who answered these questions 3-4 days a
week or more were accepted as meeting the exhaustion criterion.
Low physical activity (3) was assessed using the Minnesota
Leisure Physical Activity Questionnaire [26]. Weekly calories
spent on activities are calculated using a standard algorithm. This
variable is classified according to gender. Men: Those who show
physical activity less than 383 Kcal per week are considered frail
for this criterion. Women: Those who show physical activity less
than 270 Kcal per week were considered frail for this criterion.
Slow gait speed (4) was calculated by looking at the walking speed
at 4.57 meters. Weakness (5): According to the measurement
made with Jamar hand dynamometer (Takei A5401, Japan), it
was interpreted according to body mass index. According to these
criteria, patients with 3 or higher points are reported as ‘frail’,
those with 1 or 2 points as ‘pre-frail’, and those with 0 point as
‘non-frail’.
Translation
Firstly, the FRAIL Scale, consisting of 5 questions, was translated
from English to Turkish. To ensure the language validity of the scale,
a group of specialists checked the Turkish translation after it was
completed. After the translation was checked, the Turkish version
was translated to English, its original language, by a translator who
did know the original form of the test. Specialists and translators
came together and decided upon the final version of the Turkish
FRAIL scale. Accordingly, language validation was provided with
the method of “forward-backward translation”. The compliance
between and within the independent observers were tested. The
FRAIL Scale was implemented on 21 patients by a second researcher
who did not know the outcome of the scale on the same day to test
the compliance between the independent practitioners. To examine
the test-retest compliance, the FRAIL Scale was re-implemented on
27 patients between 7-15 days by the first researcher with similar
outpatient clinic conditions to examine the test-retest compliance,
and the received scores were recorded. FIND and Fried Index were
performed by another researcher.
Ethics
After the permission of J. E. Morley who developed the FRAIL
Scale was obtained [8], the study protocol was evaluated and
approved by the local Ethics Committee (Hacettepe University,
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GO 17/91-37, 28.02.2017). Informed consent was obtained from
all the patients.
Statistical Analyses
Statistical analysis was performed using the IBM SPSS Statistics
22.0 software. The number of patients included in the study
was decided by power analysis. The conformity of the numeric
variables, whose descriptive statistics was given first, to a
normal distribution was examined by using visual (histograms
and probability graphs) and analytical methods (Kolmogorov-
Smirnov/Shapiro-Wilk tests). Descriptive statistics were given
for the variables with a normal distribution by using mean and
standard deviation (mean±SD) values, and for the variables
without a normal distribution by using median and minimum-
maximum values. Categorical variables were stated as numbers
and percentages (%). Cronbach’s alpha coefficient was used to
test the internal consistency of the FRAIL Scale. The correlations
between the FRAIL Scale, FIND Scale, Fried Index, MMSE,
and other numeric variables were checked with the Spearman
correlation coefficient. Test-retest and interrater reliability
were examined with the intraclass correlation coefficient. The
difference in quantitative variables (gender, education status,
etc.) according to the FRAIL groups (robust-non-frail, pre-frail
and frail) was investigated with the Chi-Square or Fisher’s Exact
tests. The variables with a normal distribution between the Frail
groups were compared via the one-way analysis of variance, and
those without a normal distribution via the Kruskal-Wallis test.
The significance of the differences was tested by the Student
T-test (for one-way analysis of variance) and Mann-Whitney
U test (for Kruskal-Wallis) with a Bonferroni correction for
multiple comparisons (significance level α = 0.05/m, with m =
number of multihypothesesesis tested). Since there were three
different groups (robust, pre-frail, frail), three different pairwise
comparisons were performed and the adjusted P-value was
found to be 0.05 /3 = 0.016.
Receiver operating characteristic (ROC) evaluation was made
by grouping frail and non-frail and the Kappa coefficient was
calculated. A Kappa coefficient of 0.80 and above was interpreted
as a perfect fit. If the area under the ROC curve (AUC) was close
to 1, it was considered to have excellent diagnostic accuracy, and
sensitivity and specificity values were
​​ determined. A 5% type I
error level was used to infer statistical significance.
3. RESULTS
The mean age of the patients participating in the study was
75.45±5.20, and 69.4% were women. According to the FRAIL
Scale, 42.4% of the patients were robust (n:36), 24.7% were
pre-frail (n:21), and 32.9% were frail (n:28). When the mean
age of groups of the patients were reviewed, frailty was shown
to increase as the age advanced, which was found statistically
significant (p=0.008). Women were seen to be more frail than
men (p=0.015). From the robust group to the frail group ADL,
IADL, MMSE, MNA sf, CDT score, and influenza strength
decreased and were found to be statistically significant (p
<0.001). As the degree of frailty increased, the score of the
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Turkish validation of the FRAIL Scale Original Article

Yesavage GDS was observed to increase (p=0.001). Patients’ The FRAIL Scale used in our study was found to have an
demographic characteristics and results of the comprehensive extremely high correlation with the FIND Scale (Spearman
geriatric assessment are given in Table I. 0.956, p<0.001), Fried Index (Spearman 0.934, p0.001), and
clinical frailty score (Spearman 0.877, p0.001) (Table II). A
Table I. Demographic characteristics of the patients and results of the
significant correlation was observed between the FRAIL Scale,
comprehensive geriatric assessment age, and comprehensive geriatric assessment components
Robust Pre-frail Frail
(p<0.001) (Table III).
p
(n:36) (n:21) (n:28)
Age, year, mean±SD 72.8±6.05 75.95±7.40 79.79±6.06 <0.001
Table II. The correlation between the frailty parameters and the FRAIL
Female gender, n (%) 18 (32.2) 19 (30.5) 22 (37.3) 0.015 Scale
Education level, n (%)
Illiterate 5 (13.9) 7 (33.3) 7 (25.0) 0.856 The FRAIL Scale
Primary School 18 (46.2) 9 (42.9) 12 (42.9) and the correlation p
Secondary school 4 (11.1) 2 (9.5) 12 (7.1) coefficient
High school 5 (13.9) 1 (4.8) 3 (10.7) The FIND Scale 0.976 <0.001
University 4 (11.1) 2 (9.5) 4 (14.3) Fried Frailty Index 0.934 <0.001
Living environment, 6 (16.7) 2 (9.5) 2 (7.1) 0.293 The Comprehensive Geriatric 0.877 <0.001
n (%) 17 (47.2) 9 (42.9) 9 (32.1) Assessment and the Clinical Frailty
Alone 13 (36.1) 10 (47.6) 13 (46.4) Score
With Spouse 0 (0) 0 (0) 4 (14.3)
Other
BMI, kg/m², mean±SD 29.46±5.67 28.0±6.19 28.09±6.91 0.812 Table III. The correlation between the FRAIL Scale, demographic
Smoking status, n (%) 0.99 characteristics and comprehensive geriatric assessment components
Never used 26 (72.2) 16 (76.2) 20 (71.4) The FRAIL Scale and the
Ex-smoker 8 (22.2) 4 (19.0) 7 (25.0) p
correlation coefficient
Active smoker 2 (5.6) 1 (4.8) 1 (3.6) Age 0.444 <0.001
Drinking alcohol, n (%) 2 (5.6) 0 (0.00) 0 (0.00) 0.99 BMI -0.138 0.212
Number of drugs, 4.17±2.69 5.05±2.62 7.07±4.03 0.014 Number of comorbidities 0.50 <0.001
mean±SD
ADL -0.615 <0.001
Number of 3 (0-8) 3 (1-8) 6 (1-9) <0.001
IADL -0.753 <0.001
comorbidities (%)
MMSE score -0.644 <0.001
Number of 4 (11.1) 3 (14.3) 10 (35.7) 0.038
hospitalizations in the MNA-SF score -0.722 <0.001
last year, n (%) Yesavage GDS score 0.472 <0.001
Number of falls, n (%) 6 (16.7) 5 (23.8) 22 (76.8) <0.001 CDT score -0.49 <0.001
Urinary incontinence, 8 (22.29) 10 (47.6) 23 (82.1) <0.001 Handgrip -0.650 <0.001
n (%) Number of falls 0.544 <0.001
Vaccination, n (%) *BMI: Body mass index, ADL: Activities of Daily Living, IADL: Instrumental
Influenza vaccine 10 (27.8) 6(28.6) 11(39.3) 0.803 Activities of Daily Living, MMSE: Mini-Mental State Examination, MNA-sf: Mini
Pneumococcal vaccine 4(11.1) 2(9.5) 8(28.6) 0.119 Nutritional Assessment short-form, GDS: Geriatric Depression Scale, CDT: clock-
Katz ADL score, 5.81±1.01 5.81±0.60 4.04±1.87 <0.001 drawing test
mean±SD
Lawton-Brody IADL 7.75±0.69 6.57±2.09 3.21±2.82 <0.001
score, mean±SD The FRAIL Scale consists of 5 sub-groups: fatigue, resistance,
MNA-SF score, 13.22±1.78 11.62±3.01 8.50±3.01 <0.001 ambulation, weight loss, and illnesses. When all the sub-sections
mean±SD of the FRAIL Scale were evaluated separately and together, they
MMSE score, mean±SD 28.08±2.9 25.90±4.74 20.11±6.50 <0.001 were found to exhibit high reliability (Internal Consistency
CDT score, mean±SD 4.72±1.91 4.10±1.95 2.11±0.18 <0.001 coefficient >0.60) (Table IV). The intraclass correlation
Yesavage GDS score, 2.50±3.08 4.24±3.39 6.33±4.19 0.001 coefficient was calculated for the reliability of the interrater test
mean±SD
and found to be 1.00 (100% compliant). Test results performed
Handgrip, kg, 25.67±6.1 20.02±5.89 14.65±5.94 <0.001
mean±SD
by two independent practitioners were found to be similar. The
* SD: Standard deviation, BMI: Body mass index, ADL: Activities of Daily
intraclass correlation coefficient calculated for the test-retest
Living, IADL: Instrumental Activities of Daily Living, MNA-sf: Mini Nutritional was 1.00 (100% compliant). The test scores revealed by the same
Assessment short-form, MMSE: Mini-Mental State Examination, CDT: clock- practitioner in two different time slots were completely similar.
drawing test, GDS: Geriatric Depression Scale Thus, the scale was highly stable over time.

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Table IV. Cronbach’s alpha internal consistency coefficients of the FRAIL
Scale sub-headings
The FRAIL Scale sub-headings Internal Consistency coefficient
Fatigue 0.727
Resistance 0.682
Ambulation 0.677
Illnesses 0.787
Weight loss 0.822
Total 0.787
The result of the ROC analysis performed for the FRAIL scale is
shown in Figure 1. The Kappa agreement coefficient was found
to be 0.952. According to the FIND scale, the specificity of the
FRAIL Scale was 94.7% and the specificity was 100%.
AUC: 0.993, p<0.001
AUC, Area under the curve; ROC, receiver operating characteristic curve
Figure 1. ROC analyses of the FRAIL Scale
4. DISCUSSION
In this study, the Turkish version of the FRAIL Scale was
examined for its reliability and validity in the Turkish geriatric
population. As a result of the study, the FRAIL Scale was found
to have high internal consistency and reliability in test-retest
and interrater administration. In our study, the FRAIL Scale
was revealed to be valid and reliable in screening frailty in the
geriatric age group in our country.
The FRAIL scale was developed by Morley, et al., in 2012 [8].
The validity and reliability of the FRAIL Scale, which is an
effective and reliable scale to measure frailty, in Turkish society
had not been tested before. There are many scales being used to
measure frailty. None of these scales have been considered gold
standard scales. Determination of frailty according to the results
of the comprehensive geriatric assessment can be accepted as the
most appropriate diagnostic method. Besides, using an easily
applicable, effective, and reliable scale will facilitate determining
frailty. For this reason, we planned to study the FRAIL Scale,
which is a practical scale, for validity and reliability. In our
practice in the outpatient clinic of geriatrics, patients are noted
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as non-frail, pre-frail, and frail by the doctor as a result of their
general examinations and comprehensive geriatric assessments.
In our study, the correlation between the result of the clinical
frailty assessment and the FRAIL Scale was checked, and it
was found extremely high. In our clinic, patients are followed
up by experienced geriatricians, and it can be determined after
anamnesis and examination whether patients are clinically frail
or not. It is not possible to determine the level of the frailty of
patients only clinically and with anamnesis in other centers
where there are no geriatricians available; objective tests should
be used. The FRAIL Scale can be used as a screening test due
to its advantages such as being short and easily applicable
characteristics.
Comprehensive geriatric assessment is considered a gold
standard method for frailty screening in many sources [27].
In our study, the correlation between the FRAIL scale and the
Comprehensive geriatric assessment tests was checked, and
significant correlations were observed in the results. In its
reliability and validity studies in Korea, Italy, and Mexico, the
FRAIL scale was shown to be associated with IADL [9, 10, 28].
According to the FRAIL Scale, as the level of frailty increases,
patients become more dependent, go into cognitive remission,
and have poorer nutrition. The FRAIL scale and the Yesavage
GDS were observed to be correlated at a moderate level. Our
study supports the literature data, and a positive relationship
was demonstrated between frailty and depression [29]. As the
FRAIL Scale score increased, the score received from CDT and
MMSE score decreased. In light of these results, it is seen that
frailty does not only remain in the dimension of physical frailty
but also interacts with all the other geriatric syndromes. In this
respect, its determination via appropriate assessment and scales
is of great importance.
In many studies conducted in different parts of the world, the
female gender has been found to be associated with frailty. In our
study, it was found that 23.1% of men were frail, while 37.3% of
women were frail, and the difference between both genders was
found to be significant. Similar results were obtained in other
studies in which FRAIL Scale validation was performed [8-10].
Similar to the literature data, in our study, it was found that the
degree of frailty increased with increasing age. In the validity
and reliability study of the FRAIL Scale conducted in Mexico,
the patients were grouped as 60-69 years old, 70-79 years old,
and 80 years old and above, and it was found that the frailty
increased as the age increased [10]. Italian and Korean studies
observed that the relationship between frailty and age was not
statistically significant [9, 28]. In our study, it was observed that
the relationship between education level and frailty was not
statistically significant, similar, in a study conducted in Italy.
But it was shown in other studies that as the level of education
increased, frailty decreased [8-10]. It was observed that the
education levels of the patients participating in our study were
generally low and it was thought that this factor might have
affected the results.
The FIND scale and the Fried index have been proven in previous
studies to be valid and reliable screening scales for showing
vulnerability in Turkish society. In our study, its relations with
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the FRAIL Scale was examined. It was found that the FRAIL
Scale correlated very highly with the FIND scale and the Fried
index and was statistically significant. Its use is more practical
because it can be evaluated in a short time in comparison with
the Fried index. This correlation shows that the FRAIL scale can
be used easily and reliably as a frailty test.
In our study, the internal consistency coefficient of the FRAIL
Scale was found to be high; high homogeneity was observed
when all its sub-sections were evaluated separately and together.
In the reliability of the interrater test, the test results revealed
by the two independent practitioners were found completely
similar. The test scores obtained by the same practitioner in
two different time slots were found completely similar; hence,
the scale was observed to exhibit high consistency over time. In
a previous study on validity and reliability in Korea, Italy, and
Mexico, the internal consistency coefficient, interrater and test-
retest were not calculated [9, 10, 28].
This study had some limitations. Firstly, the patient group
included in the study may not represent the general geriatric
population. Conducting the study in different centers and
different settings, such as institutionalized older adults and
inpatients will increase reliability and validity. Secondly, the
reliability study on test-retest and interrater could be carried
out with a low number of patients. The stability of the test can
be ensured when it is repeated with more people over time. In
the study, independent evaluators evaluated the FRAIL Scale
in different environments, unaware of each other. Interrated
reliability of 1.00 is one of the surprising results of the study.
Evaluation of a small group may have been the reason for this
situation.
Conclusion
Since frailty is a multifactorial clinical condition, it is quite
difficult to measure. Many easily applicable and reliable
methods have been developed to determine frailty in geriatric
clinics. There is a need for scales tested for Turkish validity and
reliability, which can be used practically to clinically determine
frailty. The FRAIL scale developed by Morley et al. has been
proved to be a valid and reliable scale to measure frailty in many
countries. In this study, the Turkish version of the FRAIL Scale
was examined for its reliability and validity in the Turkish older
population. As a result of the study, the Turkish version of the
FRAIL scale has been found to have high internal consistency,
and test-retest and independent practitioner reliability.
Compliance with Ethical Standards
Ethical Approval: After the permission of J. E. Morley who
developed the FRAIL Scale was obtained the study protocol
was evaluated and approved by the local Ethics Committee
(Hacettepe University, GO 17/91-37, 28.02.2017). Informed
consent was obtained from all the patients.
Financial Disclosure: The authors declared that this study has
received no financial support.
Conflict of Interest: The authors report that they have no
conflict of interest.
154
Marmara Medical Journal
Original Article
Authors’ Contribution: BABH, RTD and BBD: Study
conception and design, BABH, RTD, CB, CO, HC, BBD, MC
and MH: Data collection, BABH, RTD, BBD, and EK: Analysis
and interpretation of results, RTD, BABH, and BBD: Draft
manuscript preparation. All authors reviewed the results and
approved the final version of the manuscript.
REFERENCES
[1] Walston J, Hadley EC, Ferrucci L, et al. Research agenda
for frailty in older adults: toward a better understanding
of physiology and etiology: summary from the American
Geriatrics Society/National Institute on Aging Research
Conference on Frailty in Older Adults. J Am Geriatr Soc
2006;54:991-1001. doi: 10.1111/j.1532-5415.2006.00745.x.
[2] Gross AL, Xue QL, Bandeen-Roche K, et al., Declines and
impairment in executive function predict onset of physical
frailty. J Gerontol A Biol Sci Med Sci 2016;71:1624-30. doi:
10.1093/gerona/glw067.
[3] Sirven N, Rapp T. The cost of frailty in France. Eur J Health
Econ 2017;18:243-53. doi: 10.1007/s10198.016.0772-7.
[4] Qin Y, Hao X, Lv M, Zhao X, Wu S, Li K. A global perspective
on risk factors for frailty in community-dwelling older adults:
A systematic review and meta-analysis. Arch Gerontol Geriatr
2023;105:104844. doi: 10.1016/j.archger.2022.104844.
[5] Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: a call
to action. J Am Med Dir Assoc 2013;14:392-7. doi: 10.1016/j.
jamda.2013.03.022.
[6] Wang X, Hu J, Wu D. Risk factors for frailty in older adults.
Medicine (Baltimore) 2022;101:e30169. doi: 10.1097/
MD.000.000.0000030169.
[7] Aarts S, Patel KV, Garcia ME, et al. Co-presence of
multimorbidity and disability with frailty: an examination
of heterogeneity in the frail older population. J Frailty Aging
2015;4:131-8. doi: 10.14283/jfa.2015.45.
[8] Morley JE, Malmstrom TK, Miller DK. A simple frailty
questionnaire (FRAIL) predicts outcomes in middle aged
African Americans. J Nutr Health Aging 2012;16:601-8. doi:
10.1007/s12603.012.0084-2.
[9] Jung HW, Yoo HJ, Park SY, et al. The Korean version of the
FRAIL scale: clinical feasibility and validity of assessing
the frailty status of Korean elderly. Korean J Intern Med
2016;31:594-600. doi: 10.3904/kjim.2014.331.
[10] Díaz de León González E, Gutiérrez Hermosillo H,
Martinez Beltran JA, et al. Validation of the FRAIL scale in
Mexican elderly: results from the Mexican Health and Aging
Study. Aging Clin Exp Res 2016;28:901-8. doi: 10.1007/
s40520.015.0497-y.
[11] Dong L, Qiao X, Tian X, et al. Cross-cultural adaptation and
validation of the FRAIL scale in Chinese community-dwelling
older adults. J Am Med Dir Assoc 2018;19:12-7. doi: 10.1016/j.
jamda.2017.06.011.
[12] Gardiner PA, Mishra GD, Dobson AJ. Validity and
responsiveness of the FRAIL scale in a longitudinal cohort
http://doi.org/10.5472/marumj.1297696
Marmara Med J 2023;36(2): 149-156

Hymabaccus et al.
Turkish validation of the FRAIL Scale
study of older Australian women. J Am Med Dir Assoc
2015;16:781-3. doi: 10.1016/j.jamda.2015.05.005.
[13] Lopez D, Flicker L, Dobson A. Validation of the frail scale
in a cohort of older Australian women. J Am Geriatr Soc
2012;60:171-3. doi: 10.1111/j.1532-5415.2011.03746.x.
[14] Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW.
Studies of illness in the aged: the index of ADL: a standardized
measure of biological and psychosocial function. Jama
1963;185: 914-9.
[15] Arik G, Varan HD, Yavuz BB, et al. Validation of Katz index
of independence in activities of daily living in Turkish older
adults. Arch Gerontol Geriatr 2015;61:344-50. doi: 10.1016/j.
archger.2015.08.019.
[16] Lawton MP, Brody EM. Assessment of older people: self-
maintaining and instrumental activities of daily living.
Gerontologist 1969;9:179-86. PMID:5349366.
[17] Folstein MF, Folstein SE, McHugh PR. “Mini-mental
state”. A practical method for grading the cognitive state of
patients for the clinician. J Psychiatr Res 1975;12:189-98. doi:
10.1016/0022-3956(75)90026-6.
[18] Güngen C, Ertan T, Eker E, Yaşar R, Engin F. Standardize
mini mental test’in Türk toplumunda hafif demans tan› s› nda
geçerlik ve güvenilirliği. Turk Psikiyatri Derg. 2002;13:273-81.
PMID: 12794644.
[19] Guigoz Y, Lauque S, Vellas BJ. Identifying the elderly at risk for
malnutrition. The Mini Nutritional Assessment. Clin Geriatr
Med 2002;18:737-57. doi: 10.1016/s0749-0690(02)00059-9.
[20] Sarikaya D, Halil M, Kuyumcu ME, et al. Mini nutritional
assessment test long and short form are valid screening tools
in Turkish older adults. Arch Gerontol Geriatr. 2015;61:56-60.
doi: 10.1016/j.archger.2015.04.006.
[21] Yesavage JA, Brink TL, Rose TL, et al., Development and
validation of a geriatric depression screening scale: a
preliminary report. J Psychiatr Res 1982-1983;17:37-49. doi:
10.1016/0022-3956(82)90033-4.
155
Marmara Medical Journal
Original Article
[22] Stähelin HB, Monsch AU, Spiegel R. Early diagnosis of
dementia via a two-step screening and diagnostic procedure.
Int Psychogeriatr 1997;9 Suppl 1:123-30. doi: 10.1017/
s104.161.0297004791.
[23] Cesari M, Demougeot L, Boccalon H, et al. A self-reported
screening tool for detecting community-dwelling older
persons with frailty syndrome in the absence of mobility
disability: the FiND questionnaire. PLoS One. 2014;9:e101745.
doi: 10.1371/journal.pone.0101745.
[24] Arık G, Canbaz B, Karabulut E, Kara O, Sumer F, Ulger Z.
Disabilite yokluğunda kırılganlık sendromunun saptanması
için güvenir bir tarama testi:FİND anketi türkçe formu 9.
Akademik Geriatri Kongresi 2016.
[25] Fried LP, Tangen CM, Walston J, et al. Frailty in older adults:
evidence for a phenotype. J Gerontol A Biol Sci Med Sci
2001;56:M146-56. doi: 10.1093/gerona/56.3.m146.
[26] Taylor HL, Jacobs DR Jr, Schucker B, Knudsen J, Leon AS,
Debacker G. A questionnaire for the assessment of leisure
time physical activities. J Chronic Dis 1978;31:741-55. doi:
10.1016/0021-9681(78)90058-9.
[27] Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein
LZ. Comprehensive geriatric assessment: a meta-analysis
of controlled trials. Lancet 1993;342(8878):1032-6. doi:
10.1016/0140-6736(93)92884-v.
[28] Poli S, Pandolfini V. Social Factors & Elderly Frailty – An
Application of the Frail Scale in Italy. BMS 2016; 131: 92-100.
doi: 10.1177/075.910.6316642720.
[29] de Vries NM, Staal JB, van Ravensberg CD, Hobbelen JS,
Olde Rikkert MG, Nijhuis-van der Sanden MW. Outcome
instruments to measure frailty: a systematic review. Ageing
Res Rev 2011;10:104-14. doi: 10.1016/j.arr.2010.09.001.
http://doi.org/10.5472/marumj.1297696
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 Marmara Medical Journal
Hymabaccus et al.
Turkish validation of the FRAIL Scale Original Article

Supplementary file: Turkish version of the FRAIL Scale

FRAİL ÖLÇEĞİ 1 0
Yorgunluk: “Son 4 haftanın ne kadarında kendinizi yorgun hissettiniz?” 1 veya 2 3 veya 4 veya 5
1=Her zaman 2=Çoğu zaman 3=Bazı zamanlarda 4=Çok az zaman 5=Hiçbir zaman
(cevap 1 veya 2 ise 1 puan verilir, diğerlerinin hepsine 0 puan verilir)
Direnç: “Kendi başınıza ve yardımcı cihaz kullanmadan, 10 basamak merdiveni dinlenmeden çıkmakta zorluk çeker Evet Hayır
misiniz?”
Dolaşma: “Kendi başınıza ve yardımcı cihaz kullanmadan, birkaç yüz metreyi yürümekte zorluk çeker misiniz?” Evet Hayır
Hastalık: “Bir doktor size hiç şu hastalıklarınızın olduğunu söyledi mi?” 5-11 hastalık 0-4 hastalık
(Hipertansiyon, diyabet, kanser (küçük cilt kanseri dışında), kronik akciğer hastalığı, kalp krizi, konjestif kalp yetmezliği,
anjina, astım, artrit, inme, böbrek hastalığı)
(0-4 hastalık=0 puan, 5-11 hastalık=1 puan)
Kilo kaybı: “Kıyafetleriniz üzerinizdeyken ama ayakkabısızken kaç kilosunuz? (şu andaki ağırlık)” ≥%5 kilo kaybı <%5 kilo kaybı
“Bir yıl önce …yılının…ayında kıyafetleriniz üzerinizdeyken ama ayakkabısızken kaç kiloydunuz? (bir yıl önceki ağırlık)”
Ağırlık değişikliği yüzdesi şu formül ile hesaplanır:
((bir yıl önceki ağırlık-şu andaki ağırlık)/bir yıl önceki ağırlık)x100
Ağırlık değişikliği yüzdesi >5 ise (%5 kilo kaybını temsil eder) 1 puan verilir, <5 ise 0 puan verilir)
TOPLAM

http://doi.org/10.5472/marumj.1297696
156 Marmara Med J 2023;36(2): 149-156